SURGICAL SITES INFECTION - lasuth.org.ng 2017. Vol 3.3 Surgical Site... · Clear or hemoserous...

Editor-in-Chief: Prof Idowu, Olufemi E. Neurological surgery Division, Department of Surgery, LASUCOM/LASUTH, Ikeja, Lagos, Nigeria.

Copyright- Frontiers of Ikeja Surgery

2017; Volume 3:3 1

CLINICAL VIGNETTE2017; 3:2

SURGICAL SITES

INFECTION

SURGICAL SITES

INFECTION

Copyright- Frontiers of Ikeja Surgery

2017; Volume 3:32

DR OLAGUNJU, TUNDE AJANIDepartment of Surgery,

Lagos State University Teaching Hospital, IKeja, Lagos, Nigeria

HISTORICAL PERSPECTIVE

Galen (130-200 CE)- was the first to opined that pus from wounds inflicted by the gladiators heralded healing

Koch (Professor of Hygiene and Microbiology,1843-1910)- first recognized the cause of infective foci as secondary to microbial growth in his 19th century postulates

Semmelweis (1818-1865) demonstrated a fivefold reduction in puerperal sepsis by hand washing

Louis Pasteur (French bacteriologist, 1822-1895)- revolutionized the entire concept of wound infection. Lister recognized that antisepsis could prevent infection

Joseph Lister (Professor of Surgery, London, 1827-1912)- used Carbolic acid (phenol) during operations to maintain aseptic conditions

Alexander Fleming (microbiologist, London, 1881-1955) credited with the discovery of penicillin

Halsted (Professor of Surgery, Johns Hopkins University, 1852-1922)- introduced use of rubber gloves

Copyright- Frontiers of Ikeja Surgery 2017; Volume 3:3

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INTRODUCTION AND EPIDEMIOLOGYSurgical site infections (SSI) are a

type of surgical infection thathas always been a majorcomplication of surgery andtrauma and has beendocumented for 4000-5000years

DEFINITIONSSIs are infections of the tissues, organs, or spaces exposed by surgeons during performance of an invasive procedure occurring within 30 days or 1 year if an implant is present

Account for 14-16% of the estimated 2 million nosocomial infections affecting hospitalized patients in the United States

World Health Organization survey demonstrated a prevalence of nosocomial infections in the range of 3-21%, with wound infections accounting for 5-34% of the total

2002 survey report by the Nosocomial Infection National Surveillance Service (NINSS), indicates that the incidence of hospital acquired infection related to surgical wounds in the United Kingdom is as high as 10% and costs the country's National Health Service approximately 1 billion pounds annually


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CLASSIFICATION

CDC classification

1. Incisional SSIs: can be superficial or deep

2. Organ/space SSIs: affect the rest of the body other than the body wall layers


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SUPERFICIAL INCISIONAL SSI Involves only the skin or subcutaneous tissueIncludes at least one of the followingpurulent drainage is present (culture documentation not required)organisms are isolated from fluid/tissue of the superficial incisionat least one sign of inflammation (eg, pain or tenderness,

induration, erythema, local warmth of the wound) is presentwound is deliberately opened by the surgeonsurgeon or clinician declares the wound infectedwound is not considered a superficial incisional SSI if a stitch

abscess is present; if the infection is at an episiotomy, a circumcision site, or a burn wound; or if the SSI extends into fascia or muscle


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DEEP INCISIONAL SSI

Involves deep soft tissues (eg, fascia and/or muscle) of the incision

Includes at least one of the following

purulent drainage is present from the deep incision but without organ/space involvement

fascial dehiscence or fascia is deliberately separated by the surgeon because of signs of inflammation

a deep abscess is identified by direct examination or during reoperation, by histopathology, or by radiologic examination;

the surgeon or clinician declares that a deep incisional infection is present


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ORGAN SSI

Occurs within 30 days of the operation or within 1 year if an implant is present

Involves anatomic structures not opened or manipulated during the operation

Includes at least one of the following:

purulent drainage is present from a drain placed by a stab wound into the organ/space

organisms are isolated from the organ/space by aseptic culturing technique

an abscess in the organ/space is identified by direct examination, during reoperation, or by histopathologic or radiologic examination

a diagnosis of organ/space SSI is made by the surgeon or clinician


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RISK FACTORSPATIENT FACTORS

Older age

Immunosuppression

Obesity

Diabetes mellitus

Chronic inflammatory process

Malnutrition

Smoking

Renal failure

Peripheral vascular disease

Anemia

Radiation

Chronic skin disease

Carrier state (e.g., chronic Staphylococcus carriage)

Recent operation

LOCAL FACTORS

Open compared to laparoscopic surgery

Poor skin preparation

Contamination of instruments

Inadequate antibiotic prophylaxis

Prolonged procedure

Local tissue necrosis

Blood transfusion

Hypoxia, hypothermia

MICROBIAL FACTORS

Prolonged hospitalization

Toxin secretion

Resistance to clearance (e.g., capsule formation)

Dose of Bacterial inoculum

Virulence of the organism


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CLASSES OF SURGICAL WOUNDS

Classification based on the presumed magnitude of the bacterial load at the time of surgery

Clean wounds (class I) 1-2%: include those in which no infection is present; only skin micro flora potentially contaminate the wound, and no hollow viscus that contains microbes is entered.

*Class I D wounds: are similar except that a prosthetic device(e.g., mesh or valve) is inserted

Clean contaminated wound (class II) <10%: include those in which a hollow viscus such as the respiratory, alimentary, or genitourinary tracts with indigenous bacterial flora is opened under controlled circumstances without significant spillage of contents


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CLASSES OF SURGICAL WOUNDS

Contaminated wounds (class III) 15-20%: Include open accidental wounds encountered early after injury, those with extensive introduction of bacteria into a normally sterile area of the body due to major breaks in sterile technique (e.g., open cardiac massage), gross spillage of viscus contents such as from the intestine, or incision through inflamed, albeit nonpurulent tissue

Dirty wounds (class IV) <40%: Include traumatic wounds in which a significant delay in treatment has occurred and in which necrotic tissue is present, those created in the presence of overt infection as evidenced by the presence of purulent material, and those created to access a perforated viscus accompanied by a high degree of contamination


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MAJOR FINDING ADDITIONAL FINDINGS GRADENormal healing 0

Normal healing with mild bruising or erythema

I

some bruising Iaconsiderable bruising Ib

mild erythema IcErythema plus other signs of

inflammationII

at 1 point IIaaround sutures IIb

along wound IIcaround wound IId

Clear or hemoserous discharge IIIat 1 point only; <= 2 cm IIIa

along wound; > 2 cm IIIblarge volume IIIc

prolonged drainage (> 3 days) IIIdPus IV

at 1 point only; <= 2 cm IVaalong wound; > 2 cm IVb

Deep or severe wound infection with or without tissue breakdown or hematoma requiring aspiration

V


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ASEPSIS WOUND SCORE

SOUTHAMPTON GRADING SCHEME FOR SURGICAL WOUNDS

WORK UP

Laboratory Studies

Gram stain for infective organisms and Staining for fungal elements

Tests for antigens from the organism through enzyme-linked immunoassay (ELISA) or radioimmunoassay

Detection of antibody response to the organism in the host sera.

Detection of RNA or DNA sequences or protein from the infective organism by Northern, Southern, or Western blotting, respectively

Polymerase chain reaction (PCR) to detect small amounts of microbial DNA

ultrasonography

Ultrasonography can be applied to the infected wound area to assess whether there is a collection for which drainage is required


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TREATMENTMainstay of treatment is source control or draining of the infected area.

For a superficial SSI this involves opening the wound at the skin and subcutaneous levels and cleansing the wound, along with dressing changes twice or three times a day

Occasionally, sharp debridement to allow healing of the open wound is necessary. wound-suctioning devices can also be used to minimize the discomfort from more frequent dressing changes and possibly to accelerate wound healing.

Organ SSI - source control can generally be achieved with percutaneous drainage. when it involves a more diffuse area of a human cavity (i.e., diffuse peritonitis, mediastinitis), surgical drainage is encouraged and would include repair of any anatomic cause of infection if present

The use of antibiotics is not the standard for treatment of incisional SSI. They are recommended only as adjunctive therapy when surrounding cellulitis occurs or when treating a deep SSI


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COMPLICATIONS

SIRShyperthermia (> 38°C) or hypothermia (< 36°C)tachycardia (> 90 min–1, no β-blockers) or tachypnea(> 20 min–1)white cell count > 12x109 /L or < 4 x109 /L Sepsis: SIRS with a documented infectionSevere sepsis- sepsis with evidence of one or more organ dysfunction;

respiratory (acute respiratory distress syndrome), cardiovascular (septic shock), renal (acute tubular necrosis), hepatic, blood coagulation systems or central nervous system. Septic manifestations and multiple organ dysfunction syndrome (MODS) are mediated by the release of cytokines such as the interleukins

Septic shock- sepsis plus either hypotension (refractory to intravenous fluids) or hyperlactatemia

MODS may progress into multiple system organ failure (MSOF). In this state, the body’s resistance to infection is reduced


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PREVENTION

MICROORGANISM LOCAL PATIENT

PREOPERATIVE Shorten preoperative stay

Antiseptic shower

preoperatively

Appropriate preoperative hair

removal or no hair removal

Avoid or treat remote site

infections

Antimicrobial prophylaxis

Appropriate preoperative hair removal or no hair removal

• Optimize nutrition • Preoperative

warming • Tight glucose

control (insulin drip)

• Stop smoking


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PREVENTION


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Prevention- Intra-operative agentsNAME PRESENTATION USES COMMENTSChlorhexidine

(Hibiscrub)

Alcoholic 0.5%

Aqueous 4%

Skin preparation; Surgical scrub

in dilute solutions in open wounds

Has cumulative effect. Effective against

Gram-positive organisms, vegetative bacteria,

mycobacteria, moderately active against fungi and

viruses, spore germination is also inhibited and relatively

stable in the presence of pus and body fluids

Cetrimide

(Savlon)

Aqueous Skin preparation; Hand-washing

Instrument and surface cleaning

Good detergent action (quaternary ammonium

compoundssurface-active agent). Ineffective against

bacterial spores, tubercle bacilli, fungi, viruses and many

gram-negative bacteria (Pseudomonas spp. may grow in

stored contaminated solutions)

Povidone–iodine

(Betadine)

Alcoholic 10%

Aqueous 7.5%

Skin preparation; Surgical scrub in

dilute solutions in open wounds

Safe, fast-acting, broad spectrum. Some

sporicidal activity. Anti-fungal

Iodine is not free but combined with

polyvinylpyrrolidone (povidone)

Alcohols 70% ethyl, isopropyl Skin preparation Should be reserved for use as disinfectants

Hypochlorites Aqueous preparations

(Eusol, Milton, Chloramine T)

Instrument and surface cleaning

(debriding agent in open wounds?)

Toxic to tissues

Hexachlorophane Aqueous bisphenol Skin preparation Hand-washing Has action against Gram-negative organisms


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CDC GUIDELINE FOR PREVENTION OF SSI Advise patients to have a full-body shower or

bath with soap (antimicrobial only as needed) or an antiseptic agent no earlier than the night before the day of surgery.

Before cesarean delivery, administer antimicrobial prophylaxis before incision.

In most cases, use an alcohol-based agent for skin preparation in the operating room.

It is not necessary to use plastic adhesive drapes with or without antimicrobial properties to prevent SSIs.

For clean and clean-contaminated procedures, do not give additional prophylactic antimicrobial doses after closing the surgical incision, even if the patient has a drain in place.

Do not apply topical antimicrobial agents to the incision

Maintain intraoperative glycaemic control in diabetic and non diabetic patients, targeting blood glucose levels of less than 200 mg/dL.

Maintain patient normothermia.

In patients with normal lung function undergoing general anaesthesia with endotracheal intubation, administer a higher fraction of inspired oxygen (FIO2) during surgery and after extubation in the immediate postoperative period.

Do not withhold transfused blood products as a means to prevent SSIs.


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REFERENCES

1. Williams NS, Bulstrode CJK, O'Connell PR. Bailey and Love’s short practice of surgery 25th edition. Taylor and Francis. 2008.

2. Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery: The Biological Basis of Brunicardi FC, Andersen DK, BilliaModern Surgical Practice, 18th edition. Philadelphia: WB Saunders, 2007.

3. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG. Schwartz’s principles of surgery 10th edition. McGraw-Hill Professional Publishing. 2014.

4. Hemant Singhal. Surgical Wound Infection Clinical Presentation. Medscape. May 2017.

5. Centers for Disease Control and Prevention Guidelines for the Prevention of Surgical Site Infection, 2017.

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